NUTRITIONAL ASSESSMENT FORM

(Indoor Patient)

 PERSONAL INFORMATION:
Date: _________________

PERSONAL
INFORMATION
PATIENT NAME AGE GENDER MARITAL
STATUS

HEIGHT WEIGHT SOCIO-ECONOMIC CONTACT

STATUS NUMBER

 NO OF FAMILY MEMBERS
Members in family .

 FAMILY MEDICAL HISTORY

______________________________________
 ADDRESS
_______________________________________

 OTHER HISTORY
 Do you have children? Yes No
 Are you pregnant? Yes No
 ACTIVITY LEVEL

Low Moderate High

 TYPE OF EXERCISE
Walk
Exercise
 DURATION
_______________________________

 STRESS LEVEL

Low Moderate High

 SLEEPING CYCLE
Sleep time Wake time Sleeping hours
  ANY MEDICAL CONDITION YOU HAVE DIAGNOSED WITH:

Hypertension Diabetes Constipation

Diarrhea Obesity Vomiting

Any Addiction? _______________

Current Medication: _____________

 FLUID REQUIREMENT
Amount of water intake daily
Glasses/day .
 TEMPERATURE OF WATER
Cold temperature Warm temperature Room temperature

 YOUR DAILY FOOD INTAKE FROM FOOD GROUPS

Food items Quantity Types

Meat
Milk
Fruits
Vegetables
Fats
Cereals

 CERTAIN FOODS THAT YOU NOT EAT?

---------------------------------------------------------------------------------------------------------------------
 ANY FOOD ALLERGY OR INTOLERANCE

_________________________________________________

 FAST FOOD FREQUENCY:

 Daily ----------

 Once a week -------

 Twice a week -----------

 Once a month --------

1. ANTHROPOMETERY:
“Refers to measurements of human individual “
MEASURMENTS:

1: BMI
Formula

BMI = wt. (kg) / ht (m) 2

 Normal: 18-25
 Underweight: <18
 Overweight: 25-30
 Obese: 35-40
2: BEE

Formula:

 Male
= {66+ [(13.7* wt (kg)+ (5* ht (cm) ] - (6.8 * age (year) }

 Female:
=655+ [(9.6 * wt (kg)] + [(1.7 * ht (cm) ]– [(4.7 * age (years) ]

3. Weight _____________

4: Height ____________

5: Waist circumference ___________

6: Hip circumference _______________

BMI: kg/m2

BEE: Kcal/day

TEE: Kcal/day

IBW: Kg

Fluid Requirements: glasses of water

2. PHYSICAL/CLINICAL ASSESSMENT

General Signs and ⮚ Loss of appetite Zinc

⮚ Pica-eating of non-nutritive
Symptoms substances
⮚ Loss of taste
⮚ Cold intolerance

Growth Failure ⮚ Failure to increase in

(Children) stature or weight and
⮚ excessive curvature of the
spine

Behavior ⮚ Easily fatigued, listless, Protein-energy malnutrition

apathetic, depressed,
nervous, irritable
⮚ Inability to concentrate,
complaints of insomnia
⮚ Poor work capacity

Skin ⮚ Dry, flaky, rough Essential fatty acids

⮚ Bed sore, poor wound
healing, edematous
⮚ Excessive bruising
⮚ Keratinization
⮚ Pinpoint, purplish
hemorrhagic spots
⮚ Symmetrical dermatitis
⮚ Itchy skin- pruritus
⮚ Carotenoderma- yellow
discoloration of skin
noticeable on the face and
trunk

Hair ⮚ Thin, sparse, dry,

lusterless, easily plucked
out
⮚ Hair loss
⮚ Change in pigments with
distinct bands
⮚ Dandruff, scalp hair loss

Face ⮚ Pale Iron

⮚ Scaling around nose
⮚ Swollen (edema)

Eyes ⮚ Pale, Dry and scaly at Iron

corners
⮚ Sensitive to light, itching
⮚ Increased vascularity
⮚ Night blindness, Bitot’s
spots, soft cornea,
exophthalmia
⮚ Conjunctival dryness
Lips ⮚ Fissuring at corners
⮚ Swollen, puffy
⮚ Cracking and peeling of
skin on the lips

Tongue ⮚ Pale Iron, Vitamin-B12

⮚ Swollen
⮚ Raw, scarlet red
⮚ Magenta red
⮚ Atrophy of papillae
⮚ Smooth, shiny and sore
⮚ Enlarged veins under the
tongue with micro-
hemorrhages

Mouth ⮚ Cracking at the corners of

the mouth
⮚ Recurrent mouth ulcers
⮚ Atrophic glossitis

Iron, Folate and Vitamin-B12

Teeth ⮚ Mottled enamel

⮚ Caries

Gums ⮚ Spongy, swollen, bleeding

Nails ⮚ Brittle, ridged, spoon

shaped, pale nail beds

Gastrointestinal ⮚ Diarrhea
⮚ Constipation
Dehydration, Fiber,
Magnesium, Potassium

Muscles ⮚ Wasted
⮚ Sore, painful
⮚ Weak
⮚ Loss of limb musculature
⮚ Muscle cramps
⮚ Calf muscle pains after
minimal exercise
⮚ Excessive calf muscle
tenderness
⮚ Walking with a waddling
gait
⮚ Difficulty getting up from
Magnesium, Potassium,
a low chair or climbing the
 stairs or weakness of Sodium
shoulder muscles
⮚ Bowed legs
⮚ Twitching of facial
muscles when tapping on
the facial nerve in front of
the ear: Chvostek’s sign

Skeletal ⮚ Poor posture, delayed

closing of fontanelles
(infant), knock knees,
bowed legs, bending of
ribs, enlarged joints
⮚ Fleeting joint pain

2. Biochemical Assessment:
Laboratory Test Normal Ranges Patient’s Value
Serum Albumin (depends 3.3 – 5.0 g/dl
on method of analysis)
Senior: 3.2 – 4.4

Newborn: 2.9 – 5.5

To age 3: 3.8 – 5.4

3 – adult: 3.3 – 5.5

Alkaline phosphatase 19 – 74 IU/L

Newborn: 50 – 275

Infant: 100 – 330

Child: 90 – 230

Adult: 100 – 250

Blood Urea Nitrogen 4 – 22 mg/dl 28 mg/dl

(BUN)
Senior: 8 – 18

Paeds: 10 – 20

Newborn/infant: 8 – 28

Serum calcium 8.5 – 10.5 mg/dl

Chloride 100 – 106 mEq/L

Cholesterol 150 – 200 mg/dl

 Children <200

Total CO2 23 – 30 mEq/L

Creatinine 0.7 – 1.5 mg/dl 1.05 mg/dl

Senior: 0.6 – 1.2

Newborn: 0.4 – 1.2

0 – 4 yr: 0.1 – 0.7

4 – 10 yr: 0.2 – 0.9

10 – 16 yr: 0.3 – 1.1

Ferritin 12 – 300 µg/L

<6 months: 25 – 200

6 months – 15 yr: 7 – 140

Globulin 2.3 – 3.5 g/dl

Glucose fasting levels 70 – 100 mg/dl Random B.G:-

<50 yr: 60 – 100 70 mg/dl
Senior: 55 – 125

Premature: 20 – 60

Newborn: 20 – 110

Child: 60 – 100

Hematocrit 39 – 51% 38.4%

36 – 15%

Senior: 30 – 54%

Newborn: 40 – 70%

Infant: 30 – 49%

Child: 30 – 42%

Adolescent: 34 – 44%

Hemoglobin 12 – 17 g/dl 14.0 g/dl

Senior: 10 – 17

Newborn: 14 – 24

Infant: 10 – 15

Child: 11 – 16
Iron 60 – 175 µg/dl

Newborn: 100 – 200

4 months – 2 yr: 40 – 100

Child: 85 – 150

Lymphocytes count (total 15,00 – 4,000 mm3 (closely 30%

% lymphocytes x WBC ) involved with immune
system)

Magnesium 1.4 – 2.3 mEq/L

Phosphorus 2.5 – 4.7 md/dl

Senior: 2.3 – 3.7

Newborn: 4 – 9

Infant: 4.6 – 6.7

Child: 4.0 – 6.0

Potassium 3.5 – 5.0 mEq/L

Protein, total 6 – 8.4 g/dl

Reticulocyte count 25,00 – 75,000 cells

RBC count (multiply 4.4 – 5.7 Total RBC’S:-

automatic counter values
x 1 million for total 1= ) 4.0 – 5.3 4.78
Senior: 3.0 – 5.0

(x 10/mm3)

(mil/mm3)

Sodium 136 – 145 mEq/L

Transthyretin (pre- 10 – 40 mg/dl

albumin or thyroxine-
binding pre-albumin)

TIBC estimated 250 – 450 µg/dl

transferring= (0.8 x
TIBC) – 43

Transferring saturation 20 – 50%

Triglycerides 40 – 150 mg/dl

Uric acid 4.0 – 8.5 mg/dl 4.2 mg/dl

2.7 – 7.3
 Senior: 2.9 – 8.8

2.4 – 7.2

WBC count 4.5 – 10.6 thousand/mm3 6,900/Cumm

Zinc 85 – 120 µg/dl

3. DIETARY ASSESSMENT

● 24 Hour Recall
LUNCH

BREAKFAST

MORNING
SNACK

LUNCH

AFTERNOO
N SNACK

EVENING 1Pomegran 1 Fruit exchange

SNACK ate
DINNER

AFTER

DINNER

● Diet History
 ● Food Frequency Checklist

● SGA Form

24 HOUR RECALL

DIET HISTORY

FOOD FREQUENCY CHECKLIST

MEAT AND FISH

FOODS AND NEVER LESS 1-3 PER ONCE 2-4 5-6 ONCE 2-3 4-5 6+PER
AMOUNTS THAN A PER A PER PER DAY
ONCE/MONTH MONTH WEEK PER WEEK DAY DAY DAY
WEEK

BEEF

CHIKEN Yes

MUTTON Yes

FISH

LIVER
KIDNEY

CEREALS

PORRIDGE Yes

BREAD

PASTA

RICE Yes

BROWN

PIZZA Yes

CORNFLAKES
 DAIRY PRODECT AND FATS

LOW FAT
YOGURT

FULL FAT Yes

YOGURT

EGG Yes

BUTTER

SALAD
CREAM

SWEETS AND SNACKS

SWEET BISCUITS Yes

CAKES

MILK PUDDING

ICE CREAM Yes

CHOCOLATES Yes

PEANUTS

FRUITS

BANANA Yes

APPLE Yes

PEAR

ORANGE

STRAWBERRY

MELON

DRY FRUITS Yes

OTHERS

VEGETABLES

CARROTS Yes

SPINACH Yes

CABBAGE Yes
POTATO

TOMATO Yes

CUCUMBER

PEAS Yes

OTHERS

SOUPS, SAUCES, AND SPREADS

VEGETABLE
SOUP

MEAT SOUP Yes

TOMATO

KETCHUP

JAM

PEANUT
BUTTER

OTHERS

Worksheet A

Subjective:.

Objective:

● Anxiety
● Neurosis
● Severe Ureteric Pain
● Low Fiber
● Low Iron
● Low vitamin B12
● Low Magnesium
● Low Potassium
● Low Folate
● Low Protein
● Low Zinc
 Assessment:

Name:

Age:

Weight:

Height:

BMI: Kg/m2

BEE: Kcal/day

IBW: Kg

Fluid Requirement: glasses of water

Plan:

o High Fiber, medium proteins, low fat, low sodium, high potassium, medium calcium, high fluid
diet, high iron.

Worksheet B

Goals Plan Sources

Worksheet C

DIET CHART
Meal Name Timing Food items Quantity Form

Early Morning 6-7am

Breakfast 7-8am

Brunch 10-11am

Lunch 1-2pm

Snacks 4-5pm

Dinner 6-7pm

After Dinner 9-10pm

REQUIREMENTS
Total Calories Requirement-------------------------

Total Fluid Requirement----------------------------

RECOMMENDATIONS:

o Follow Up Notes_________________________________

Consultant Nutritionist Intern’s signature